Tuesday, December 23, 2008

The Evidence Gap - Drug Rehabilitation or Revolving Door?

Their first love might be the rum or vodka or gin and juice that is
going around the bonfire. Or maybe the smoke, the potent marijuana
that grows in the misted hills here like moss on a wet stone.

But it hardly matters. Here as elsewhere in the country, some users
start early, fall fast and in their reckless prime can swallow,
snort, inject or smoke anything available, from crystal meth to
prescription pills to heroin and ecstasy. And treatment, if they get
it at all, can seem like a joke.

"After the first couple of times I went through, they basically told
me that there was nothing they could do," said Angella, a 17-year-old
from the central Oregon city of Bend, who by freshman year in high
school was drinking hard liquor every day, smoking pot and sampling a
variety of harder drugs. "They were like, 'Uh, I don't think so.' "

She tried residential programs twice, living away from home for three
months each time. In those, she learned how dangerous her habit was,
how much pain it was causing others in her life. She worked on
strengthening her relationship with her grandparents, with whom she
lived. For two months or so afterward she stayed clean.

"Then I went right back," Angella said in an interview. "After a
while, you know, you just start missing your friends."

Every year, state and federal governments spend more than $15
billion, and insurers at least $5 billion more, on substance-abuse
treatment services for some four million people. That amount may soon
increase sharply: last year, Congress passed the mental health parity
law, which for the first time includes addiction treatment under a
federal law requiring that insurers cover mental and physical
ailments at equal levels.

Many clinics across the county have waiting lists, and researchers
estimate that some 20 million Americans who could benefit from
treatment do not get it.

Yet very few rehabilitation programs have the evidence to show that
they are effective. The resort-and-spa private clinics generally do
not allow outside researchers to verify their published success
rates. The publicly supported programs spend their scarce resources
on patient care, not costly studies.

And the field has no standard guidelines. Each program has its own
philosophy; so, for that matter, do individual counselors. No one
knows which approach is best for which patient, because these
programs rarely if ever track clients closely after they graduate.
Even Alcoholics Anonymous, the best known of all the substance-abuse
programs, does not publish data on its participants' success rate.

"What we have in this country is a washing-machine model of addiction
treatment," said A. Thomas McClellan, chief executive of the
nonprofit Treatment Research Institute, based in Philadelphia. "You
go to Shady Acres for 30 days, or to some clinic for 60 visits or 60
doses, whatever it is. And then you're discharged and everyone's
crying and hugging and feeling proud — and you're supposed to be cured."

He added: "It doesn't really matter if you're a movie star going to
some resort by the sea or a homeless person. The system doesn't work
well for what for many people is a chronic, recurring problem."

In recent years state governments, which cover most of the bill for
addiction services, have become increasingly concerned, and some,
including Delaware, North Carolina, and Oregon, have sought ways to
make the programs more accountable. The experience of Oregon, which
has taken the most direct and aggressive action, illustrates both the
promise and perils of trying to inject science into addiction treatment.

More ...